The lymphatic system has two primary immunologic functions:
activating the inflammatory response and controlling infections. In addition, the lymphatic system drains protein-containing fluid from
the tissue and conducts it in a unidirectional flow to the circulatory system. When there is a blockage in this drainage, the result is the swelling of a body part, often an extremity. This is referred to as lymphedema, an abnormal accumulation of lymph fluid.

Lymphedema is categorized as primary or secondary. Primary lymphedema is defined as impaired lymphatic flow due to lymph
vessel aplasia, hypoplasia, or hyperplasia. This type is an inherited deficiency in the lymphatic channels of unknown origin. Secondary lymphedema is caused by known precipitating factors. The most
common causes in the United States are surgical removal of the
lymph nodes (i.e., in connection with a mastectomy), fibrosis
secondary to radiation, and traumatic injury to the lymphatic
system. Filariasis is the leading cause of lymphedema throughout
much of the tropical world.

Currently, lymphedema can be treated by many methods such as: Compressive garments, wrapping, elevation, surgery, pneumatic compression devices or Complex Decongestive Physiotherapy (CDP). This policy addresses only the CDP method.

Complex Decongestive Physiotherapy has been referred to by
several terms including: non- invasive complex lymphedema therapy (CLT), early conservative lymphedema management, complicated physiotherapeutics, manual lymphedema treatment (MLT), multi-
modal lymphedema therapy, and palliative lymphedema therapy.
For purposes of consistency, the term CDP will be used.

Each CDP session normally consists of four phases:

• Skin care including cleansing, lubrication, debriding and administration of antimicrobial therapy;
  
  
• Manual lymph drainage involving a gentle massage technique
  that is carried out in a predetermined manner aimed at
  redirecting lymph and edema fluid towards adjacent,
  functioning lymph systems;
  
  
• Multi-layered compression wrapping (bandages) to prevent any reaccumulation of excavated edema fluid and to prevents the ultrafiltration of additional fluid into the interstitial space; and
  
  
• Individualized exercises with the bandage to enhance lymphatic flow from peripheral to central drainage components. These exercises are aimed at augmenting muscular contraction, enhancing joint mobility, strengthening the limb, and reducing
  the muscle atrophy that frequently occurs secondary to lymphedema.

It is expected that physical therapy education sessions would usually
last for 1 to 2 weeks, with the patient attending 3-5 times per week, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment are not expected unless the patient continues treatment at home.

The physical therapy billed in conjunction with the manual lymph drainage therapy will be subject to all national and local policies for physical therapy.

The coverage of the physical therapy would only be allowed if all of the following conditions have been met:

• There is a physician documented diagnosis of lymphedema; and the physician specifically orders CDP.
• The patient is symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety.
• The patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen.
• The services are being performed by a health care professional who has received specialized training in this form of treatment.

The physical therapy services for CDP must be provided either by or under the direct personal supervision of the physician or independently practicing therapist.

CPT Codes
97001     Physical therapy evaluation
97002     Physical therapy re-evaluation
97003     Occupational therapy evaluation
97004     Occupational therapy re-evaluation|
97110     Therapeutic procedure, one or more areas, each 15 minutes;
                therapeutic exercises to develop strength and endurance,
                range of motion and flexibility
97140      Manual therapy techniques (eg, mobilization/manipulation,
                manual lymphatic drainage, manual traction), one or more   
                regions, each 15 minutes
97535       Self care/home management training (e.g., activities of daily
                 living (ADL) and compensatory training, meal preparation,
                 safety procedures, and instructions in use of adaptive
                 equipment) direct one on one contact by provider, each 15
                 minutes

ICD-9 Codes That Support Medical Necessity
457.0     Postmastectomy lymphedema syndrome
457.1     Other lymphedema
757.0     Hereditary edema of the legs (congenital lymphedema)

Coding Guidelines
It is expected that procedure code 97140 will be utilized when the
manual lymph drainage is performed, procedure code 97535 for the instruction of bandaging, exercises and self care, and procedure code 97110 when performing the individual exercises.

When an initial evaluation or periodic re-evaluation is performed, separate reimbursement may be made. For these evaluations,
physical and occupational therapists should use codes 97001, 97002, 97003, and 97004, and physicians should use the applicable Evaluation and Management codes.

It is not appropriate to automatically bill with an evaluation and management service each time a patient goes for the physical therapy treatment. An evaluation and management should not be used unless
all of the components of the visit have been met.